Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0381, written 25 Oct 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Oct 2016 |
|---|---|
| Reference | 2016-0381 |
| Deceased | Kevin Hefferman |
| Coroner | Graham Danbury |
| Coroner area | Hertfordshire |
| Category | Road (Highways Safety) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
CORONER’S OFFICE AREA OF HERTFORDSHIRE The Old Courthouse, St Albans Road East, Hatfield, Hertfordshire, AL10 OES OX: 100702 Hatfield Tel: 01707 292780 Fax: 01707 897399 REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Mr Jim O'Sullivan Chief Executive Highways England Federated House London Road Dorking Surrey RH4 18Z CORONER lam Graham Danbury, Deputy Coroner for Hertfordshire CORONER’S LEGAL POWERS | make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (investigations) Regulations 2013. http:/Avww.legislation.gov. uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legislation.gov.uk/uksi/2013/4629/part/7/made 3 INVESTIGATION and INQUEST On 28/03/2016 | commenced an investigation into the death of Kevin Andrew Heffernan, 49. The investigation concluded at the inquest on 25 October 2016. The conclusion was Road Traffic Collision. 4 CIRCUMSTANCES OF THE DEATH On 27" March 2016 at approximately 11.35 pm Mr Heffernan was the sole occupant of his BMW X5 which he was driving westbound on the M25 in the 3” or 4" lane. Weather conditions were poor, with high winds and heavy rain as Storm Katie was crossing southern England. At a point ial west of Junction 23, approaching the point where the motorway crosses his vehicle veered to the left, colliding with 2 other vehicles and leaving the motorway through the nearside bridge barriers, falling approximately 15 foot and landing on it's roof. Mr Heffernan's death was confirmed at the scene. The cause of death was Multiple Traumatic Injuries CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. — (1) Police officers who attended the scene noticed, in addition to standing water on the carriageway, a flow of water across the westbound carriageway at or near the point where the BMW began to veer to the left. They measured the flow of water as being approximately 16 metres wide flowing towards the nearside. A police officer gave evidence that in the 5 years prior to this incident 18 collisions had been recorded at this spot, with rain or water on the carriageway mentioned in 6 cases. (3) The evidence of the police officers was that this flow of water may well have been a contributory factor in Mr Heffernan losing control of his vehicle, and that it could be a source of danger to road users in cases of heavy rain. ACTION SHOULD BE TAKEN in my opinion action should be taken to prevent future deaths and | believe you have the power to take such action. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 20 December 2016. |, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION | have senta = of my report to the Chief Coroner and to the following Interested Person: || widow of the deceased.. | am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. Dated 25 October 2016 van) Signature. een 2 Deputy Coroner for Hertfordshire
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
. highways england Our ref: Mr Graham Danbury Hertfordshire Coroner's Office The Old Courthouse St Albans Road East Hatfield Hertfordshire AL10 OES Dear Mr Danbury Bridge House Guildford GU1 4LZ 22 February 2017 Response to Regulation 28 Report to Prevent Future Deaths Kevin Andrew Heffernan 27" March 2016 | refer to your Regulation 28 Report resulting from the inquest into the tragic death of Kevin Andrew Heffernan on the 27" March 2016 which was received by Highways England on 2" February 2017. Highways England Company Ltd (throughout referred to as “Highways England”) accepts the circumstances of the death as outlined in paragraph 4 of the Regulation 28 Report dated 25 October 2016. Highways England would like to extend sincere condolences to the family of Mr Heffernan for their sad loss. We note your concerns outlined in paragraph 5 of the report regarding a flow of water across the westbound carriageway at or near the point where Mr Heffernan’s vehicle began to veer to the left. The section of carriageway where Mr Heffernan’s incident occurred was subject to a range of major improvements which widened the M25 t four lanes between junction 16 and junction 23; these works were completed in the spring of 2012. These improvements were designed to the specification and standards applicable at the time and were subject to a range of design and safety checks/audits. Where it was found that the design specification could not be met then a “departure from standard” would have been approved at the time. Action taken or to be taken by Highways England We have undertaken aninitial investigation of the section of carriageway in question with the following findings: Registered office Bridge House, 1 Walnut Tree Close, Guildford GU1 412 Highways England Company Limited registered in England and Wales number 09246363 yr ¢ ™y INVESTORS * IN PEOPLE Pavement Condition An analysis of surface characteristics at this location did not find any issues in relation to rutting, longitudinal profile or skidding resistance and is therefore considered within design tolerances. It should be noted that the skidding resistance (SCRIM) is measured using a method designed to mimic wet road conditions. Carriageway Geometry Our records for this section show that the crossfall (the slope of the carriageway perpendicular to the direction of travel) of the road surface changes direction prior to the point where Mr Heffernan’s vehicle started to move out of lane. The gradient (the slope of the carriageway parallel to the direction of travel) before and after this point is within normal design parameters. It is a characteristic of highway design that crossfall change will result in an increased depth of water flowing across the carriageway, in more extreme periods of rainfall. This is not an uncommon feature in highway geometry and is taken into design consideration. Drainage Condition On 15" March 2016 the gully gratings in this location were cleared of debris to ensure no obstruction to water flowing from the carriageway. On19th April 2016 a full clean of the gullies on the anti-clockwise carriageway of the M25 between junctions 23 and 22 was carried out, along with sweeping of the v-channel: no issues affecting the operation of the drainage were identified at this time. Following your report we will undertake a further review of the design of this section of carriageway. This will include analysis of the design considerations that were made as part of the major improvement scheme and this is due to be completed in the spring of 2017. Publication Highways England is content for this response to be published in full. Please advise if ! can be of further assistance. Yours sincerely Asset Delivery Manager gt Mog, ar Ragistered office Bridge House, 1 Wainut Trae Close, Guildford GU4 4LZ £ S/F INVESTORS Highways England Company Limited registered in England and Wales number 09346363 4 A IN PEOPLE a
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